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Time to Review Medicare Drug Plan Options for 2009

Consumers can appeal if their medications will no longer be covered

November 14, 2008

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Everyone who has Medicare drug coverage should review their drug plan options for 2009, advises the Medicare Rights Center, to ensure that they will have drug coverage that best meets their needs next year.

“Even people who are currently happy with their plan need to review their options,” said Robert M. Hayes, president of the Medicare Rights Center, a national non-profit consumer service organization. “They should not assume their plans will remain the same in 2009, as most plans change their costs and benefits every year.”

Between November 15 and December 31, people with Medicare have the right to change their Medicare private drug plan or enroll in one for the first time.

Medicare drug coverage is available only through private insurance companies. People who have Original Medicare can enroll in a “stand-alone” plan, which offers only drug coverage. Most people who get their Medicare benefits through a Medicare private health plan — such as an HMO or PPO — must get their drug coverage as part of the health plan’s benefit package.

Premiums, annual deductibles, copayments, covered drugs (formulary) and participating pharmacies vary from plan to plan.

Those who currently have Medicare drug coverage (Part D) should by now have received materials that show how their plan’s costs and benefits will change in 2009. Plans are required to send out the materials, called an Annual Notice of Change (ANOC), by October 31. People who have not yet received their ANOC packet should call their plan and ask them to send it immediately. The ANOC contains important information that will help people decide whether or not to stay in their current plan.

What to do

First, make a list of the medicines you take, the dosages and how much you currently pay. You should also note which pharmacies you use regularly.

Then find out whether or not your plan will cover the drugs you take next year. Check your ANOC, but keep in mind that plans are required to send you only a shortened list of covered drugs (formulary). It is important that you call your plan and ask them to confirm the information you have.

Be sure to ask them if they will cover your drugs at the doses you need, and whether there will be any coverage restrictions (quantity limits, step therapy or prior authorization) that will require your doctor to ask for special permission before the plan will cover your medicines. Also find out if your copays will change.

If your doctor had to make a special request to your plan to cover a drug this year (such as a prior authorization or exception request), and you will need the same medication in 2009, ask your plan what you must do to make sure your plan keeps covering your drug. Your doctor may have to make a new request, and she may be able to do so before the end of this year to ensure your drug will still be covered next year.

If your plan will no longer cover a drug you are taking or is imposing a new restriction, you have the right to appeal. “Ask your plan if you can receive approval to have the drug covered for 2009 before the end of this year,” said Hayes.

Plans are required to do one of two things for their members whose drugs will not be covered in 2009.

(1) They must provide a temporary supply of the drug at the beginning of the year, and notify you that you must either switch to another medicine that is on the formulary or get an exception to continue taking the drug, or

(2) They must, before January 1, work with you and your doctor to (a) switch you to an alternative drug that is covered by the plan, and (b) process your request for an exception should that alternative not work for you. Ask your plan which option they follow (they must follow one option for all of their members), and ask them to explain their transition policy to you.

Once you have reviewed your current plan, review other options that are available in your area. If there is a cheaper plan available, now is the time to switch. The Medicare Drug Plan Finder tool at www.medicare.gov will list your options. You can also call 1-800-MEDICARE to review options and get details about the plans in your area. Some questions to ask are: